Forum, July 2009

The appearance of terror

Is there research relevant to the psychological effects of appearing terrifying? In the War Against Terror, the Terror is suicide bombers who may look harmless but blow up others with them; whereas modern gear for war and law can look savage and barbarian. Can it prevent soldiers or police feeling that they are standard bearers for humane values and liberty in democracies? A famous image of this other Terror is the 2000 photo of a US BORTAC agent in battle-gear except for metal-fenced face and bare trigger finger, pointing a submachine gun at a six-year-old boy, Elián González. The storming forces expected resistance from his Florida relatives, but was this the best way to dress for the occasion?

A popular image of civilised law and order was the lone British bobby on his beat with his funny hat, whistle, and truncheon. Lines of bobbies would control public occasions with linked arms, and sometimes lost hats. In grim times, riot police may need body armour and riot shields, or believe that they will. 'Special units' sometimes resemble 'bikies' with their demonic emblems, video-game villains, or crooks in black balaclavas and cat-burglar gear. Deliberately?Is it more effective to gear up to  look like Darth Vader rather than fellow human beings? Of course, people looking like the soul of honour can still behave most terribly. But what makes brutality more likely – knowing your image looks ferocious, or honorable, or like everyone else? Places looking vandalised become more vandalised than clean places. A mood is set What is the evidence about the effect on personnel, the more they look like dark aliens from space? In some places are local cops with plain uniforms and faces too vulnerable? Does battle-gear intimidate the baddies or arouse more enemies still? Shock and awe does not win hearts and minds.

Complex factors interact, spiralling circumstances. Morality may matter. Is it bad for people's own psyches to deliberately look like fearsome monsters for real, not merely as recreational dress-up? The US has frightful rates of violence. News photographs often show police in rough clothing and surly manner, indistinguishable from their prisoners except for which wears guns or handcuffs. Armed guards at schools surely affect students psychologically, and their spirits of freedom and feeling safe as normal.

To boost their own belligerence and terrify enemies, soldiers have often added glamour and glory with woad, tattoos, decorated faces, tall feathers or busbies, and red, gold and purple. Today's terrifying appearances are not so gorgeous – just terrifying.

Valerie Yule
Mount Waverley
Victoria
Australia

 

Improving the science and practice of psychology

I'd like to respond to the article 'How can we improve psychological science?' (May 2009). I can see the need for peer group review and for an evidence and research base (though often the research participants are psychology students or members of an aberrant population). But this reminds me of the three men working with bricks. One said he was laying bricks. The next said he was building a wall. The third said he was building a cathedral. Psychology needs to develop from laying bricks (publishing research papers) to cathedral building (finding the patterns that guide our lives).

We are perhaps the first generation in over 200 years to leave the world a worse place for those who follow after us. We are short-term, selfish, greedy and, latterly, stupid. Obviously the recent financial trauma only reinforces that view. Why do so many do jobs they dislike for four weeks annual holiday and a plasma TV? Sanity, Madness and the Futility.

Obesity is rife in England, yet in India many are short of food, water and decent shelter. Bono tells us all to do more yet moves the tax base of his group to the Netherlands for tax reasons. We are like the Gadarene swine rushing to accumulate wealth to retire early to sit on a foreign beach while being waited on by the locals.
Passion, people, energy and the battles of daily life are part of the human condition not add-ons to discard when we can. We are disassembling the component parts of who we are. Sex is now separate from love, procreation and family. Money is now separate from work, colleagues and personal identity. If this analysis has a grain of truth, then psychology should be trying to make sense of it all.

Here is one idea for work that could usefully be done. In the current issue of The Psychologist there is an advert for an MSc in Forensic Psychology. No adverts, however, for an MSc in Long-Term Medical Conditions, which affect many more people. Probably because of the funding available: he who pays the piper calls the tune. We are simply extrapolating from current trends to look into the future. To paraphrase Marshall McLuhan, it's like navigating by looking at our feet.

The body of knowledge known as mathematics set out a list of 10 big theorems to try to prove in the future.
So let's take this generic approach in psychology. Ask the people the 10 big concerns in their lives. Maybe get a grant from NESTA to pay for this work. Karl Marx said that philosophers had up to now interpreted the world; the point now is to change it. Surely this applies to psychology also. To make sense of, and survive, in the current world our values will provide the lead. The alternative is too dire to contemplate. Leadership can help us to work together in agreed ways for the common good. 
Peter Murphy
Basingstoke
 

Neuropsychologists – the European dimension

I read, with great regret, that the Health Professions Council (HPC) is not going to regulate the title 'Neuropsychologist' (News, May 2009). The question is whether those who made the decision have really thought about the consequences. Now anyone can call him/herself a neuropsychologist, which means, anyone can make assessments and reports about the state of cognitive processes, like attention, executive functions, memory and others, without adequate training or experience.

As the title 'Neuropsychologist' is recognised by the European Federation of Psychologists' Associations as a professional protected title of an area of professional psychology, what would the other professional psychological societies in Europe think of someone from the UK who calls him/herself a neuropsychologist? Would the other professional psychological societies in Europe accept a neuropsychologist with training in the UK as someone with the proper qualifications for practice in their countries?

I did all my psychological training in the UK, from BSc to PhD, and I took a different route into neuropsychology by going through the clinical psychophysiology area (biofeedback, neurofeedback). Even though I did, and still do, attend workshops, seminars and short courses related to clinical psychology, I still see myself as a neuropsychologist with clinical psychophysiology. My title is recognised and protected by professional societies like the APA in the USA, and by other professional psychological societies in Europe, like in Portugal, where I do most of my professional work, but not in the UK where I did all my training.
Here in Portugal I make neuropsychological reports for insurance companies, because those made by clinical psychologists are not recognised as done by someone with the proper training for such evaluation. I have already had a local insurance company asking me to do a neuropsychological assessment for one of their clients because the one done by a clinical psychologist from the UK was not accepted by the local court. If this is the case in Portugal, will it be the same in the rest of Europe (or anywhere else) where the title 'Neuropsychologist' is protected? Is this what is going to happen from now  on as long as the title 'Neuropsychologist' is not statutorily protected by HPC?
There is still time to correct this situation, but I  am not confident that it will happen as, unlike in other countries, in the UK neuropsychology is still considered to be a subsection of clinical psychology.
Jorge Alvoeiro
Santarem
Portugal

 

Boldly going forward on IAPT

Congratulations to the editor and to the contributors to the 'Opinion special' in the May issue. While I fully support the points made I think the analysis has the potential to take psychology, particularly clinical psychology, much further in its contribution to improving mental health. This it can do both at the level of practice and also in articulating policy guidance.

The authors (collectively) critique the 'naive' assumptions of the Layard review and the anticipated economic benefits. They argue that psychological therapies and, indeed, wider interventions, should not be travestied as a collection of models  or techniques. Psychology should exemplify this view through developing in its practice sophisticated models of mind utilising (among others) an understanding of non-conscious processing; cognition; motivational and attachment processes; the neuropsychological process engaged in affect and social relationships; and ways in which social relationships and inequality in all its guises impact on mental health. Therapy must be seen as going beyond merely facilitating coping with socially sanctioned roles. Again, psychology has the potential to provide the understanding to underpin whole systems in the delivery of better mental health, ranging from prevention and building resilience to sophisticated interventions with severe and complex cases.

Clinical psychology is, in my view, in danger of fragmenting into no more than a collection of therapies, each adhering to its own system of basic assumptions and models. As Paul Gilbert shows convincingly, these models are just not up to the job because they only address a limited range of specific psychological processes. Only clinical psychology has the potential to address the spectrum of biological, psychological and social processes that influence both human distress and well-being. Formulation based on this understanding is the key, not only to individual interventions, but to interventions with groups and families, communities, and indeed at national policy level. Formulation, as an alternative to the medical model of mental health, is based on research informing a better understanding of the psychological processes leading to distress and well-being.

This can take psychology into the realm of articulating advice that is at odds with the received wisdom of government policy and popular opinion. But it is an approach from which, in my view, it must not resile. Instead it must 'boldly go' into the arena of communicating to those in power and to the general public evidence-based ways in which we can be happier and healthier. It must also assertively reclaim the territory ceded to economists and medical practitioners.
Barry Greatorex
Derby

 

Clark et al. (Forum, June 2009) accuse us of 'caricature' and 'misinformation' in our special opinion piece on 'Beyond Cognitive Therapy.' Despite the fact that we were at pains to see value in both IAPT and cognitive therapy, they give the impression that we have completely rubbished IAPT and not only that, got practically everything about it wrong.

However, anyone reading all the articles in our special opinion piece, including the thoughtful articles by Paul Gilbert and Patrick Casement (which were not even mentioned by Clark et al. in their letter), will understand that we were at pains not only to critically examine IAPT, pointing out the concerns that many psychologists have, but also to provide a constructive alternative, one based firmly in psychological science and good clinical practice. Contrary to the aspersions cast at us, we sought to inaugurate a constructive dialogue, articulating many of the concerns that practitioners have relayed to us during the months we were preparing the special issue (and continue to do so in e-mails to us since publication) about the domination of IAPT, balancing that with the positive value of developing new methods of helping people who desperately need help.

We have both been researchers and practitioners in the psychological therapies. We are aware of the selectivity of research, and the qualifications that have to  be applied to claims made by researchers for what works and what does not. Psychological problems are multicausal and multidimensional. They cannot be simplistically reduced to specific illnesses; nor should it be assumed that people will get better by simply applying the 'right' (i.e. evidence-based) techniques.

While it is good to know that IAPT practitioners will pay attention to the therapeutic relationship, will do comprehensive assessments, will take into account social and community factors, and will offer a choice on interventions, the major aim of IAPT is to get people into short-term treatments quickly. Otherwise, what is distinctive about it? In the low-intensity model, what is offered is a techniques-based therapy by specially trained therapists, one largely though not exclusively based on CBT. We argued that the focus on CBT is mainly through a highly selective interpretation of the NICE guidelines. This is not good psychology, as Paul Gilbert argued, nor does it take into account the complexities of psychotherapy, as Patrick Casement illustrated. However, those who manage and fund mental health care may well see the IAPT initiative as a way of simplifying a complex process, and diverting attention and resources from other areas of psychological therapy.

We know well more than half of the signatories to the Clark et al. letter, either as former direct colleagues or as colleagues on BPS or Department of Health committees. All of them are individually able to contribute to a debate on the principal issues we have raised. If our opinion piece is a caricature, then it is curious that the two other letters regarding IAPT in the same issue of The Psychologist have not perceived it as such, but have reflected constructively on some of the points we have raised. Other psychologists are well capable of saying whether our special opinion piece caricatures or misinforms, and, crucially, of expressing their views about IAPT, and whether this approach is the best way of delivering good psychological care in the modern NHS.
John Marzillier
John Hall
Oxford
 

FORUM guest column: Beyond boundaries

Nature versus nurture is a lie. Music is not melody versus rhythm, wine is not grapes versus alcohol, and we are not environment versus genes. We are their sum, their product and their expression. They dance together and we are their performance; they are not adversaries. The art of understanding this elegant ballet is complex and arcane, but you may never realise this from the quoted results of genetic studies, because the extent to which a trait is heritable – that is, accounted for by genetics – is usually expressed as a simple percentage.

If you Google the phrase '80 per cent genetic', you will discover hundreds of sources that claim that everything from schizophrenia, to height, to intelligence has been found to be four-fifths 'genetic'. Pick any other figure and you can find everyone from psychologists,  to politicians, to journalists claiming that this or that is explained by genes to a given percentage. Geneticists know the subtlety of this percentage and why these statements (usually lifted from the results of twin studies) are misleading; but clearly many others do not.

Imagine a mental illness is described as being 80 per cent heritable. This is often taken to mean that four-fifths of an individual's risk is down to genes, but this is not the case. What it means is that 80 per cent of the variance in the measured illness was explained by genetic factors in the specific group that was studied. This might seem like a frivolous distinction, but it is key in understanding heritability and it becomes crystal clear when tackled as an example.

Imagine that we could study a population where everybody lived in an identical environment. They did the same things every day; they ate identical foods, had identical relationships and were stressed by identical events. A twin study would find that mental illness would be close to 100 per cent heritable, because if the environment is fixed, any difference must be down to genetics. In fact, twin studies would find that everything is close to 100 per cent heritable, for exactly the same reason. To flip our thought experiment on its head, if we only studied genetically identical clones, everything would be 0 per cent heritable, because any difference must be down to the environment.

These figures do not necessarily tell us anything about the potential for a trait to be influenced by nature or nurture, because heritability is rarely an immutable and absolute fact about biology; it is an overall measure of how things are for that group, at that moment. In other words, the process of measuring the influence of genetics is, itself, subject to environmental factors. It captures the dance, not the dancers.

 

Testing delays in Alzheimer's treatment

I am trying to find information about the testing programme that Primary Medical Units now seem to have for patients coming with the common symptom of increasing memory loss.

This spring my husband was given an incredibly childish test by three people, just to make sure that he did not just suffer from mental deficiency. 'Lift your left foot', 'Who is the prime minister?' – that sort of thing. We were a long way from being able to obtain the delaying drug Aricept (or any such drug). There will first be several weeks of psychometric tests to go through. No sympathy here for our wish to get something early and speedily, as recommended in all the literature on Alzheimer's disease.

The most disturbing thing is that the rules of the mental health unit seemed unshakeable. We know that the distribution of Aricept was transferred to the medical teams in the NHS this year, and this was welcomed. Now one wonders if such a decision has been given to a very tightly controlled unit in the medical service.

I appeal for more information about this issue. As we know, the number of old-age pensioners is increasing year by year; is it right to subject them to 'weeks of psychometric tests'? Perhaps our friends the BPS clinical psychologists would be willing and able to answer some of my questions.
Name and address supplied

 

Obituary

Jolanta Ossetin (1943–2009)

Jolanta Ossetin, concert pianist, clinical psychologist and neuropsychologist died on 22 April 2009 at the age of 66. She was an extraordinary woman. Jolanta studied music in Warsaw, obtaining her MA in Piano Performance in 1965. She subsequently enjoyed a successful career as a concert pianist in Poland, appearing on radio and television and performing with various orchestras in both Poland and England.

In 1970 Jolanta moved to England and in 1979 decided to switch career and study psychology, graduating from Goldsmiths College in 1983. She then completed her clinical training at the Institute of Psychiatry, showing a particular interest in neuropsychology. She was a delightfully different student on the course, enlivening parties with impromptu performances on the piano that left friends and colleagues astounded.

Jolanta's first post after qualification was as a research neuropsychologist examining cognitive functioning in epilepsy and the effects of anticonvulsant medication. She then worked for several years at the Royal Hospital for Neuro-disability in Putney, dealing with severely brain-damaged patients. Among her achievements was the use of music to bring a patient out of a 'persistent vegetative state', which received considerable attention in the media. Jolanta's subsequent career at the Devonshire Hospital involved management programmes for patients with a variety of post-traumatic brain injury backgrounds.

Her final post was at the Blackheath Brain Injury Centre where she spent the last eight years of her working life. With her usual zest for making the world a better place in the best way she knew, she reorganised the unit for patients with challenging behaviour. She set up an activity programme so that patients' days were filled with meaningful occupations, reducing their outbursts and making their behaviour much more manageable for staff and families. Her enthusiasm and belief in making change possible energised and inspired the team in Blackheath and earned her much respect from management, as well as from those who were starting their careers under Jolanta's watchful eye.

Alongside Jolanta's neuropsychology career she worked extensively as a medico-legal expert, and was highly regarded by the legal profession for her meticulous attention to detail.

Jolanta retired in 2004 to return to her first love, the piano, giving her last performance in 2008. She had been diagnosed with breast cancer in 1990 and, despite various recurrences of the disease over the years, had remained as energetic and enthusiastic about music and psychology as earlier in her career. Jolanta seemed indestructible.

Jolanta is greatly missed by her family and her many friends. A memorial concert will be held on Friday 18 September 2009 at the Wigmore Hall in London, where Jolanta made her London debut as a concert pianist. This will include musical performances (including new works commissioned in her memory), readings and reminiscences given by Jolanta's friends and family.
If you knew Jolanta and would like to attend, please e-mail her son Alex Osiatynski ([email protected]) for tickets, which are free of charge.
David Hemsley
Institute of Psychiatry
with Sylvia Hejda-Forde
 

Obituary

Vincent John Thacker (1943–2009)

John Thacker was one of the unsung heroes of educational psychology training. Although only Director of an EP training course for a comparatively brief period, he will be remembered with great affection and respect by all who worked with him or were trained by him. After battling a crippling spinal myeloma for some 15 years, John finally passed away in the company of his family on 10 May.

Having begun his university career as a medical student at Edinburgh University, John soon switched to psychology, which he found to be very much his métier. After graduating with a very good honours degree, he gained a place on the highly regarded four-year educational psychology training programme at Swansea University. There he was identified as an outstanding student with a first-class mind. His promise quickly came to fruition, following a brief period as an assistant educational psychologist in West Suffolk, when he was offered a tutor's position at Exeter to help run the rapidly emerging master's degree EP training course.

From 1974 to 1984 John's role was that of Assistant Course Director, but in 1985 he took over as the main Course Director,  a position he held with great skill and vision for the following 10 years. During that period he was responsible for the training of some 80 or 90 EPs, was a committee member and Chair of the BPS Division of Educational and Child Psychology, constructed an innovative training programme for children with behaviour difficulties known as 'Steps to Success', and collaborated with other luminaries such as Richard Pring and Chris Watkins, on books devoted to children's social, emotional and spiritual development. Whilst at Swansea, John was strongly influenced by the late Leslie Button, whose work on Active Tutoring proved inspirational to many teachers and psychologists in the South West to which they were introduced by John.

At the height of his career, when enabled by the IT revolution to begin expressing his ideas more freely in print, John was suddenly and unexpectedly diagnosed with a malignant spinal myeloma and given no more than weeks to live. His indomitable spirit and the support of his loving wife Ann turned those weeks into months and months into years. Unable to continue working and virtually immobile turned John to other interests, including his love of calligraphy. His final project, just before he died, was a beautiful representation of Chaucer's Canterbury Tales in which he took great pride. Despite being in considerable pain, John retained his tremendous sense of humour and was avid until the end to hear my stories of the latest machinations of university life, at which he would laugh uproariously. This is the image I shall always retain of him. As well as being a first-class psychologist, he was a person of great courage and integrity and a wonderful friend. He is survived by Ann, his children Jim, Jessica and Gerard, and two much-loved granddaughters. We shall all miss him greatly.

It is intended to organise a memorial service for John in St Luke's Chapel on Saturday 18 July. All former colleagues, students and friends will be welcome to attend. It would be helpful to know if you hope to attend (e-mail to [email protected] or [email protected]) so that appropriate refreshments can be arranged.
Bob Burden
University of Exeter